Alcohol Consumption in Canada

The Chief Public
Health Officers Report

on the State of Public
Health in Canada 2015
ALCOHOL
CONSUMPTION
IN CANADA
galement disponible en franais sous le titre :

Rapport sur ltat de la sant publique au Canada de 2015
de ladministrateur en chef de la sant publique:
La consommation dalcool au Canada
To obtain additional information, please contact:

Public Health Agency of Canada
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TTY: 1-800-465-7735
E-mail: publications@hc-sc.gc.ca
This publication can be made available

in alternative formats upon request.
Her Majesty the Queen in Right of Canada,
as represented by the Minister of Health, 2016
Publication date: January 2016
This publication may be reproduced for personal
or internal use only without permission provided
the source is fully acknowledged.
Cat.: HP2-10E-PDF
ISSN: 1924-7087
Pub.: 150097
A MESSAGE FROM
CANADAS CHIEF
PUBLIC HEALTH
OFFICER
Alcohol is a socially accepted part of everyday life

for most Canadians. Almost 80 percent of us drink.
Many Canadians associate drinking with pleasurable social events
such as music festivals, watching sports, parties, and relaxing.
Celebrations and milestones like weddings, anniversaries, and
awards are often toasted with alcohol.
Our society condones, supports, and in some cases promotes
drinking such as through drink of the day specials, sale prices on
certain brands, and associating alcohol with fun and sophistication.
Although handled more like a food in Canada, alcohol is a mindaltering drug and there are health risks associated with drinking.
Our low risk drinking guidelines do not mean that alcohol is harmless.
At least three million drinking Canadians risk acute illness, such
as injury, and at least four and half million risk chronic conditions
such as liver disease and cancer.
Our children grow up seeing alcohol in many aspects of their
environment and around 3000 are born with fetal alcohol spectrum
disorder each year.
I hope this report will raise awareness and stimulate frank
conversations between Canadians, especially with their loved
ones, and helps us reflect on how our society deals with this
mind-altering drug.
Dr. Gregory Taylor

Canadas Chief Public Health Officer
iv
CPHO REPORT 2015
ALCOHOL CONSUMPTION IN CANADA
TABLE OF
CONTENTS
TABLE OF
CONTENTS
ACKNOWLEDGEMENTS
KEY MESSAGES
WHAT THIS REPORT IS ABOUT
IMPACTS ON CANADIANS
19
PATHWAYS TO IMPACTS:
FROM BRAIN TO BEHAVIOUR
23
INFLUENCING FACTORS
30
POPULATION HEALTH PERSPECTIVE
35
REDUCING HEALTH IMPACTS
40
CLOSING COMMENTS
41
REFERENCES
CPHO REPORT 2015
ACKNOWLEDGEMENTS
Many individuals and organizations have

contributed to the development of The Chief
Public Health Officers Report on the State
of Public Health in Canada, 2015: Alcohol
Consumption in Canada.
I would like to express my appreciation to
the consultants who provided invaluable
expert advice:
David Mowat, MBChB, MPH, FRCPC, FFPH,
former Medical Officer of Health, Region
of Peel, Ontario;
Daryl Pullman, PhD, Professor of Medical Ethics,
Division of Community Health and Humanities,
Memorial University;
Don Mahleka, member of the Mental Health
Commissions Youth Advisory Council and
the Children and Youth in Challenging
Contexts youth advisory committee;
Jeff Reading, MSc, PhD, FCAHS, Professor,
School of Public Health and Social Policy,
Faculty of Human and Social Development,
University of Victoria;
John Frank, MD, Director, Scottish Collaboration
for Public Health Research and Policy; Chair,
Public Health Research and Policy, University
of Edinburgh; Professor Emeritus, Dalla Lana
School of Public Health, University of Toronto;
Michael Routledge, BSc (Med), MD, CCFP, MSc,

FRCPC, Chief Provincial Public Health Officer,
Manitoba;
Peter Glynn, PhD, Health Systems Consultant;
and,
Tim Stockwell, PhD, Director of the Centre for
Addictions Research of British Columbia;
Professor, Psychology, University of Victoria.
In addition, I would also like to recognize
contributions made by partners and stakeholders
who were consulted on the report under tight
timelines, including Health Canada, the Canadian
Institutes of Health Research, the Council of Chief
Medical Officers of Health, the Canadian Centre on
Substance Abuse, the Centre for Addiction and
Mental Health, the Centre for Addictions Research
of British Columbia, Mothers Against Drunk Driving,
the Canadian Public Health Association.
I would also like to sincerely thank the many
individuals and groups within the Public Health
Agency of Canada for all of their efforts and
dedication, notably my report unit team, my
support staff and members of the 2015 Core
Advisory Group.
KEY MESSAGES
This report aims to increase Canadians

awareness about the health impacts of
alcohol consumption.
Humans have a long history with mind altering
drugs, such as alcohol. Consuming alcohol
is ingrained in Canadian culture. In 2013,
an estimated 22 million Canadians, almost
80 percent of the population, drank alcohol
in the previous year. At least 3.1 million of
those Canadians drank enough to be at risk
for immediate injury and harm with at least
4.4 million at risk for chronic health effects,
such as liver cirrhosis and various forms
of cancer.
Drinking patterns matter how much and how
often a person drinks alcohol are key factors
that increase or decrease health impacts.
Canadas Low-Risk Alcohol Drinking Guidelines
provide guidance on risky drinking patterns,
including avoidance of alcohol in pregnancy.
Low risk does not equal no risk.
Social situations, family contexts and
messaging influence drinking patterns.
Exposure to alcohol through families and friends
as well as through entertainment and advertising
can strongly influence peoples motives for
drinking alcohol and their drinking patterns.
For many Canadians, drinking is associated
with many positive situations including important
celebrations, forming friendships, positive mood
and relaxation. However, risky drinking can
increase the risk for family conflict, violence,
crime including rape and traffic accidents
through impaired driving.
Our understanding of the dose-dependent

health effects of alcohol continues to evolve.
Recent research questions the health benefits
of low to moderate alcohol consumption.
Studies suggest that women are at increased risk
for breast cancer even at a low level of one drink
per day. The International Agency for Research
on Cancers World Cancer Report 2014 and the
Canadian Cancer Society state that there is no
safe limit of alcohol consumption when it
comes to cancer prevention.
Youth are particularly at risk for negative
impacts from drinking alcohol. Teenage brains
are more vulnerable to the effects of alcohol.
Families, friends and all Canadians who care
for or work with youth can play a positive role
if they recognize their influence on youths
drinking patterns and support their healthy
physical, mental and emotional development.
How we deal with alcohol in part defines our
society. Approaches such as a regulated
alcohol industry, policies on pricing and
taxation, controls on sales and availability and
minimum age laws help reduce the impact on
Canadians, especially youth. These approaches
vary across the country and may not be realizing their full potential. No single approach can
address the large variations in the needs and
drinking patterns of Canadians.
The story of alcohol is complicated. Despite the
large of amount of information available, there
are significant gaps in our understanding of
drinking patterns, risk factors, alcohols impacts
on health and the effectiveness of approaches
to reduce these impacts.
WHAT THIS
REPORT
IS ABOUT
This report explores how consuming alcohol, a common mind-altering
drug, is an important public health issue for Canadians. In 2013, an
estimated 22 million Canadians, almost 80% of the population, reported
that they drank alcohol in the previous year, a decrease from 2004.1, 2
Many Canadians who consume alcohol do so

responsibly. However, alcohol consumption is
linked to over 200 different diseases, conditions
and types of injuries.4 Of those who choose to
drink, a significant number of Canadians (at least
3.1 million) drink enough to risk immediate injury
and harm, including alcohol poisoning in some
cases. At least 4.4 million are at risk for longer
term negative health effects.1
Canadians are subjected to mixed messages
about alcohols benefits and harms. Alcohol
consumption is a complex public health issue that
can have a wide range of health impacts. Various
factors contribute to the effects of alcohol, including how much people drink, how often they drink,
what they are doing while they are drinking, as
well as their underlying state of health.
Mind-altering drugs or substances

contain psychoactive chemicals
that act on the brain to change
thinking, mood, consciousness,
and behaviour and whose use can
sometimes lead to dependence and
abuse.3
Under the Food and Drugs Act,
alcohol is identified as a food. However, alcohol contains psychoactive
chemicals making it a psychoactive
drug or substance in terms of
impacts on health.3
Why focus on alcohol?

Canadians have a long history with alcohol that
has shaped drinking patterns over time. Alcohol
is widely available and promoted in Canada.5
Canadians are exposed to messages and images
about alcohol through advertising and marketing
of alcoholic beverages and in TV shows, movies
and literature, as well as through alcohol retail
outlets within their neighbourhood. With the
majority of Canadians choosing to drink, people
are exposed to alcohol through their friends
and family, in their neighbourhoods, at social
gatherings and through social media. Generally
speaking, increased exposure and access to alcohol
are linked to increased drinking.1036
This report focuses on alcohol consumption at
the population level in Canada, in order to raise
awareness of the evidence regarding health risks.
Canadians take health risks every day. Behaviours
like how physically active people are, how many
servings of fruit and vegetables or how much
salt and fat is in the food people eat and how
much alcohol people consume can all carry some
degree of health risk. Many people who drink
underestimate how much they drink.3739 Knowing
the shorter- and longer-term risks to health
may help some Canadians pay closer attention
to their drinking and prevent negative impacts
on their health and the health of others.
Figure 1:
WHAT PSYCHOACTIVE DRUGS ARE CANADIANS USING?
Total
Men
100
Women
ESTIMATED PERCENTAGE
80
60
40
20
Alcohol
Tobacco
Marijuana
Other illicit drugs
Estimated percentage of Canadians 15 years of age and older in 2013 who consumed alcohol, marijuana and other
illicit drugs in the previous year and/or regularly smoke tobacco.1
What are Canadians using? Alcohol, tobacco,

caffeine, marijuana, cocaine, heroin, hallucinogens,
and various prescription drugs are all examples
of psychoactive drugs. In Canada, alcohol is the
most widely consumed psychoactive drug (see
Figure 1)1 except for caffeine. After water, coffee
(which contains caffeine) is the second most
consumed beverage in Canada.40
How can alcohol be harmful? Drinking alcohol
was the third highest risk factor for global disease
burden in 2010, moving up from being ranked
sixth in 1990. It was also the top risk factor for
poor health in people ages 15 to 49 years.41
Risky drinking can result in a wide range of negative impacts on society, including increased rates
of premature death, disability and disease, impaired
driving, reduced productivity, a burdened health
care system, and high financial burden to both the
individual and society.e.g.,6, 8, 9, 4248
A SNAPSHOT OF ALCOHOLS
IMPACTS ON CANADIANS:
In 2002, 4,258 deaths in Canada were
related to alcohol abuse, representing
1.9% of all deaths.6
Costs related to alcohol in Canada

equalled approximately $14.6 billion
in 2002.6
From April 2013 to March 2014,

$20.5 billion worth of alcohol was sold
in Canada.7
In 2008, impaired driving was the leading

cause of criminal death in Canada.8
Among psychoactive drugs, alcoholrelated disorders were the top cause

of hospitalizations in Canada in 2011.9
CPHO REPORT 2015
DOSE-DEPENDENT HEALTH EFFECTS
INCREASED HEALTH RISK
Table 1: AN OVERVIEW OF THE DOSE-DEPENDENT HEALTH

AND BEHAVIOURAL IMPACTS OF ALCOHOL CONSUMPTION
DIRECT EFFECTS
DISEASE AND
CONDITIONS
Risky drinking can cause:

Alcohol use disorders
Amnesia (e.g.,
Korsakoffs syndrome)
Memory loss and
blackouts
Delirium due to
a severe form
of withdrawal
Fetal Alcohol
Spectrum Disorder
(FASD)
Drinking alcohol is
linked to:
Other drug use
disorders
Brain damage
Liver disease
Various cancers
Pancreatitis
Mental health disorders
Suicide
Stomach ulcers
Hypertension
Stroke
Cardiovascular disease
Diabetes
Sexually transmitted
infections
FUNCTIONS AND
SYSTEMS
Drinking alcohol affects
the following systems:
Immune
Stress
Memory, cognition
Digestion
Heart, blood, lungs
Brain
Hormones
Muscles
Fertility
Skin
Development
BEHAVIOUR
Risky drinking can

lead to:
Risky behaviour
Impulsivity
Violence
Injury
Poor memory
Impaired
decision-making
Lack of coordination
Poor academic
performance
Impaired social
and occupational
functioning
References: 4, 42, 49, 51127
At the individual level, alcohol affects a wide

variety of biological systems in a dose-dependent
manner, leading to impacts on health, well-being,
and behaviour over both the short and long term
(see Table 1).
For example, the International Agency for Research
on Cancer (IARC) of the World Health Organization
Globally, alcohol was linked to over

3 million deaths per year in 2012,
slightly more than lung cancer and
HIV/AIDS combined.4850
(WHO) has classified alcoholic beverages, ethanol

in alcoholic beverages and acetaldehyde associated with the consumption of alcoholic beverages
as carcinogenic to humans. This means that
alcohol consumption is capable of increasing
the incidence of cancer in a population. It can
also reduce the length of time cancer is present
but inactive in the body, increase cancers
severity, and increase the number of tumours
or types of cancer present.51
The IARCs World Cancer Report 2014 and the
Canadian Cancer Society state that there is no
safe limit of alcohol consumption when it
comes to cancer prevention.
Many factors influence how alcohol affects a

persons health, including how much and how
often a person drinks, that persons specific risk
factors, and what they are doing while they are
drinking. Although controversial, studies have
shown that alcohol may also have beneficial
effects. However, benefits are dose-dependent
and apply to a select set of diseases, conditions,
situations, and segment of the population.53, 54, 56,
57, 59, 61, 6365, 69, 73, 7680, 84, 87, 89, 9092 Given that many
people who drink underestimate how much they
drink,38, 39, 128130, their perceived potential for
harm or benefit may also be inaccurate.
Is alcohol consumption the same

as alcohol abuse? No. Paying
attention to drinking patterns,
knowing what factors contribute
to health risks, and recognizing
signs can help reduce or prevent
health risks, risky drinking, alcohol
abuse, alcohol dependence, and
alcohol use disorders and their
associated harms.
EXAMPLES OF POTENTIAL HEALTH IMPACTS

SHORT-TERM
Intoxication
Delirium
Disinhibition
Psychosis
Vision
Risky behaviour
LONG-TERM
Decision-making
Memory
Anxiety
Depression
Brain damage
Stroke
Mental health
Heart disease
Hypertension
Pancreatitis
Stomach ulcers
Fatty liver disease
Hepatitis
Cirrhosis
Fertility
Injury
Motor control
Skin
Muscles
Hormones
Immune system
Stress system
Alcohol poisoning
References: 4, 42, 4649, 51127.
Cancer
Sexually transmitted infections
Alcohol and other drug use disorders
CPHO REPORT 2015
WHAT THIS
REPORT COVERS
This report focuses on the health impacts of
alcohol consumption, including how they
develop and are modified by drinking patterns
and risk factors. Included in this report are
the following sections:
1.
Impacts on Canadians explores how much

Canadians are drinking and what are the
resulting major impacts on health and society,
including potential benefits.
2. Pathways to Impacts : From Brain to

Behaviour outlines examples of how drinking
patterns can lead to impacts on the brain and
through behaviour.
3. Influencing Factors describes how different

risk and protective factors can influence the
risks for impacts from alcohol consumption.
4. Population Health Perspective provides three
examples of specific populations in Canada:
youth, women, and Aboriginal populations.
5. Reducing Health Impacts provides highlights
on how public health can address the issue of
alcohol consumption in Canada, with a focus
on primary prevention.
IMPACTS ON
CANADIANS
Identifying how much and how often people drink is a first step in
understanding consequences, benefits, and harms of alcohol consumption
on a particular population. Currently, data on alcohol consumption and
related costs and harms, particularly for trends, are limited in Canada. This
makes it difficult to capture a true picture of the impact on Canadians.
Drinking in Canada
In 2013, an estimated 22 million Canadians
15 years of age and older, almost 80% of the
population, drank alcohol in the previous year,
with the highest percentage of past year drinkers
found in 30 to 34 year olds (see Figure 2a). The
highest percentage of risky drinkers, based on
drinking over the previous week, was found in
young adults (ages 20 to 29) (see Figure 2b).1
These data only capture risky drinking in the
week previous to the survey, meaning it is a
limited snapshot.1
From April 2013 to March 2014, Canadians bought
almost 76 litres of beer, 16 litres of wine, 5 litres
of spirits, and 4 litres of other alcoholic beverages
per person.7 Proportionally, Canadians drink
more beer (51%) than spirits (27%) or wine (22%)
(see Figure 3).48
Drinking is more common in men than women,
as is risky drinking. For every year between 2003
and 2010, approximately one in three men and
one in five women aged 15 years and older who
drink reported that they drank risky amounts of
alcohol at least once a month. In the same period,
approximately 50% of young men and women
(ages 18 to 24) who drank reported undertaking
risky drinking on a monthly basis.131
Risky drinking is currently on the rise among
women, especially those 35 years of age and
older. In 2013, 56% of women aged 15 years and
older reported binge drinking (four drinks or more
in one sitting) at least once in the previous year
compared to 44% in 2004.1, 2, 132
Risky Drinking: The impacts of alcohol

are dose-dependent. In 2011, the Canadian
Centre on Substance Abuse released
Canadas Low-Risk Alcohol Drinking
Guidelines. These guidelines identify
how much is too much: 42
Drinking more than 15 standard drinks

a week for men or 10 a week for women
with more than 3 drinks a day for men or
2 for women on most days increases the
risk for long-term negative impacts on
health.
Drinking more than 4 standard drinks for

men or 3 for women in an occasion
increases the risks for short-term injury
and harm.
There are no health benefits to alcohol
consumption for youth. The potential health
benefits from alcohol do not begin until
middle age.
The evidence used to develop these
guidelines can be found at this link.
Rates of past-year drinking among Canadians

aged 15 years and older have been decreasing
from 79% in 2004 to 76% in 2013. For Canadians
aged 15 to 24, rates of past year drinking dropped
from 78% in 2004 to 73% in 2013.1, 2, 132 An
estimated 24% of Canadians almost 7 million
aged 15 years and older reported that they did
not drink in 2013.1, 2
10
CPHO REPORT 2015
Figure 2a:
DRINKING RATES IN CANADA IN 2013
100
80
60
40
20
0
1519 2024 2529 3034 3539 4044 4549 5054 5559 6064
65+
AGE GROUPS
Estimated percentage of Canadians 15 years of age and older who had consumed alcohol in the year previous to a
2013 survey.1
Figure 2b:
RISKY DRINKING RATES IN CANADA IN 2013
Risk for ShortTerm Impacts
35
Risk for LongTerm Impacts
30
25
20
15
10
5
0
1519
2024 2529 3034 3539 4044 4549 5054 5559 6064
65+
AGE GROUPS
Estimated percentage of Canadians 15 years of age and older who had consumed alcohol in the week prior to a 2013
survey in amounts that exceeded the guidelines for risks for short- or long-term impacts.1
11
How much alcohol do Canadians really drink?

Most people tend to underreport how much
alcohol they drink. Not only do people tend to
underestimate how much they and others drink,
they also tend to underestimate how harmful
alcohol is.3739, 129, 133148 In some cases, drinking
on special occasions, which is not well captured
by many surveys, can partially explain this discrepancy.149 Some surveys only capture a short
period of consumption (e.g., one week), leading
to a limited picture of consumption.1
Surveys tend to focus on drinking of regulated
alcoholic beverages (e.g., beer, wine, liquor),
meaning data on consumption of home brew
and other sources of alcohol are not captured.
Estimates on the proportion of home brew
consumed as part of the total consumption
of alcohol in Canada vary widely and depend
on the source of data used and how data are
analysed.150152
Attempts have been made to account for underreporting.e.g., 37, 129, 153155 In Canada, under-reporting
occurred more often for spirits than for beer or
wine. Canadians under the age of 45 were more
likely to under-report their alcohol consumption as
were low-risk drinkers of any age. Men and women
were similar in terms of the extent to which they
under-report their consumption of alcohol.129
How much does alcohol contribute to daily
caloric intake? Unlike many other drugs,
alcohol can count towards daily caloric intake
(see Table 2).45 The National Institutes of Health
in the United States has an alcohol calorie
calculator for a variety of different types of
alcohol. For example:
1 drink of regular beer (12 ounces) is
153 calories.
1 drink of red wine (5 ounces) is 125 calories,
while 1 glass of white wine (5 ounces) is
121 calories.
1 drink of gin, rum, vodka, whisky, or tequila
(1.5 ounces) is 97 calories. This does not
account for calories in added ingredients,
such as carbonated beverages or juice.
Figure 3:
TYPE OF DRINK CONSUMED
BY CANADIANS IN 2010
(PERCENTAGE OF ALCOHOL
CONSUMPTION PER CAPITA
IN LITRES)48
WINE
22%
SPIRITS
27%
BEER
51%
Adjusted rates for risky drinking: To adjust

Canadian drinking data from 2008 to 2010 for
under-reporting, data on drinking over the
previous year and sales data were incor
porated. These adjusted data suggest that:155
Estimates of the average rates of pastyear risky drinking among Canadians ages
15 years and older who drink rose from
16.7% to 38.6% for short-term harm and
from 6.8% to 27.3% for long-term harm.
Most underage drinking and drinking by

young adults occurs in bouts of heavy
drinking (i.e., exceeding the short-term
guidelines) rather than in a low level of
drinking spread out over several days.
12
CPHO REPORT 2015
Table 2: EXAMPLES OF HOW DAILY CONSUMPTION OF

ALCOHOL CAN CONTRIBUTE TO DAILY CALORIC INTAKE
CALORIES
APPROXIMATE %
OF RECOMMENDED
DAILY CALORIC INTAKE
For men between the ages of 19 to 50 years who are somewhat active
(recommend daily calories: 26002700)
4 drinks of regular beer
612
23%
4 drinks of red wine
500
19%
4 drinks of white wine
484
18%
4 drinks of gin, rum, vodka, whisky, or tequila
388
14.5%
For women between the ages of 19 to 50 years who are somewhat active
(recommended daily calories: 20002100)
3 drinks of regular beer
459
22.5%
3 drinks of red wine
375
18.5%
3 glasses of white wine
363
17.5%
3 glasses of gin, rum, vodka, whisky, or tequila
291
14%
Note: These calculations are based on recommendations from Canadas Low-Risk Alcohol Drinking Guidelines and
Canadas Food Guide
Costs of Alcohol in Canada

Costs related to alcohol consumption can be
explored through sales and the overall cost to
society. Sales can provide an indirect measure
of consumption and cost to the individual, while
overall cost shows the high financial burden of
alcohol in Canada.
Sales of Alcoholic Beverages: Sales of alcoholic
beverages can indirectly reflect how much
Canadians are drinking. They also show how
much Canadians are spending on alcoholic
beverages. Sales continue to increase in Canada.
From April 2013 to March 2014, Canadians bought
$20.5 billion worth of alcohol, which was 1.1% higher
than the previous year. Sales of ciders, coolers, and
other refreshment alcoholic beverages accounted
for most of this increase, although sales of wine
and spirits are also increasing. Beer remains the
most popular alcoholic beverage in Canada.7
The alcohol industry ensures that regulated
alcoholic beverages are available to Canadians
while sales contribute to the Canadian economy.
For example, production and sales provide
employment while taxes and pricing provide
revenue for provincial and federal governments.156

Net income and government revenue from
the control and sale of alcoholic beverages
was $10.5 billion in 2013/2014.7 In most provinces,
revenue from alcohol does not exceed societal
costs from drinking.156
Overall Costs: The estimated cost of alcohol
abuse in Canada in 2002 was $14.6 billion (see
Figure 4).6 This information is dated and the
cost has likely changed over time. In fact, more
recent data show that the cost of hospitalizations
for substance use disorders from psychoactive
drugs has been increasing, reaching $267 million
in 2011, over half of which was due to alcohol.9
These data do not fully capture hospitalizations
from alcohol consumption as they are limited to
alcohol use disorders.9
Impaired driving also creates a high financial
burden, through both law enforcement and damage
from accidents. When the health and social costs
for deaths, injuries and damage to vehicles are
included, costs related to impaired driving (including alcohol and other drugs) were estimated at
over $20.6 billion a year in 2010.157
13
Figure 4:
BREAKDOWN OF ESTIMATED COSTS OF ALCOHOL ABUSE
IN CANADA IN 20026
LAW ENFORCEMENT
$3.1 BILLION
HEALTH CARE
$3.3 BILLION
TRAFFIC ACCIDENT DAMAGE
$757 MILLION
FIRE DAMAGE
TOTAL
$156 MILLION
$14.6
ADMINISTRATIVE COSTS
$66 MILLION
BILLION
PREVENTION AND RESEARCH
$53 MILLION
LOSSES ASSOCIATED WITH
WORKPLACE DAMAGE
$17 MILLION
LOST PRODUCTIVITY
$7.1 BILLION
Alcohol-Related Mortality
and Morbidity in Canada
In Canada, alcohol is one of the top ten risk
factors for disease among all Canadians and the
top risk factor for Canadians aged 15 to 49 years.158
In 2002, 4,258 deaths in Canada were related
to alcohol abuse.6 The majority of these deaths
were due to alcoholic liver disease, motor vehicle
accidents and alcohol-related suicides.6
In terms of health, consuming alcohol can have
long- and short-term effects on the body with
each having different underlying, although
sometimes overlapping, causes. Drinking can also
impact well-being over both the short and long
term.
Globally, alcohol contributes to: 48
100% of deaths and disability from

alcohol use disorders and fetal alcohol
spectrum disorder;
50% of deaths and disability for

liver disease;
20-30% of deaths and disability from

oral/pharynx cancer, laryngeal cancer,
oesophageal cancer, pancreatitis,
violence or self-harm;
10-15% of deaths and disability from liver

cancer, tuberculosis, epilepsy, haemorrhagic stroke, unintentional injuries, falls,
traffic injuries, drowning or fires; and
less than 10% of deaths and disability

from breast cancer, heart disease,
ischaemic stroke, lower respiratory
infections or HIV.
14
Long-term Impacts
Long-term impacts can be caused by a variety
of mechanisms that are usually disease-specific.
Outlined below are examples of long-term
impacts of alcohol consumption, most of which
are dose-dependent:
Alcoholic liver disease: The number of deaths in
Canada from alcoholic liver disease has been
increasing, from 1,104 in 2000 to 1,535 in 2011.159
Risk factors for developing alcoholic liver disease
include dose, frequency of drinking, type of drink,
genetics, and the presence of other disorders. 160-162
Fetal alcohol spectrum disorder (FASD): FASD
is a lifelong chronic disorder that is the leading
known cause of preventable developmental
disability in Canada. 163, 164 It is estimated
that more than 3,000 babies are born with
FASD every year in Canada and that more than
330,000 people in Canada are affected.165, 166
Estimates suggest that 2% to 5% of people in
western countries may be affected by FASD.167
Higher rates have been estimated for some
Aboriginal communities in Canada. 168
Alcohol is a teratogen (i.e., a substance that
crosses the placenta in a pregnant woman to the
baby and can cause malformation of an embryo)
that can permanently affect the development of
the fetus, resulting in a child born with FASD.
FASD includes physical and central nervous
system defects with impacts ranging from mild
to severe. The greatest effects are on the brain,
resulting in cognitive, behavioural and emotional
impacts.169
CPHO REPORT 2015
What about binge drinking and long-term

health?
The impact of binge drinking (or heavy
episodic drinking) on long-term health is
a complex and evolving story. Evidence
suggests that binge drinking is linked to
negative impacts on the liver, the brain,
cancer and cardiovascular health. 189-192
In some cases, the impacts of binge drinking
are no different than drinking the same
amount over a longer period. 193, 194 Binge
drinking is also linked to higher rates of
behaviours that put peoples health at risk
(e.g., smoking).189, 193
People with FASD experience difficulties with

judgment, planning, memory, impulsivity, communication, and other impairments. As a result, they
are at greater risk for experiencing problems at
school, mental health issues, problems with alcohol
and other drugs, employment challenges, and
involvement with the criminal justice system.170
Experts recommend that the safest choice is to
not drink any type of alcohol at any time during
pregnancy or when planning to become pregnant.42
This recommendation may be difficult to follow as
50% of pregnancies are unplanned.171 Mothers are
also advised to limit alcohol consumption while
breastfeeding and plan their breastfeeding schedule to ensure that alcohol is eliminated from their
system before breastfeeding.172, 173
Examples of how alcohol consumption

leads to disease: 96, 109, 115, 127, 189, 195199
Alcohol is toxic for the liver, heart,

pancreas and nervous system.
Alcohol has a dose-dependent effect

on the immune system with low doses
being beneficial and higher doses
being detrimental.
There are many ways that alcohol might

lead to cancer. For example, some
metabolic by-products that result from
drinking can cause tumours. This effect
may depend on genetics.
Evidence suggests that alcohol impacts

various aspects of the cardiovascular
system, some being direct (e.g., increased
cell death in the heart) and some being
indirect (e.g., through damage to
the liver).
Cancer: Cancer is linked to 30% of all Canadian

deaths, making it the leading cause of death in
Canada. An estimated 40% of Canadians will
develop cancer at some point during their lifetime.174 Alcohol is considered to be carcinogenic
and is strongly associated with an increased risk
for certain types of cancer such as colorectal
cancer, breast cancer, some cancers of the central
nervous system, and cancers of the larynx, pharynx,
oesophagus, and liver. 4, 48, 49, 52, 72, 82, 83, 88, 175181
15
Heavy drinking increases the risk for oral, pharyngeal, and oesophageal cancers by five times, for
laryngeal cancer by two and a half times and for
colorectal and breast cancers by 50%.182, 183 There
are sex differences in these effects. For example,
men have a higher risk for alcohol-related colorectal
cancer than women. Recent research shows that
one drink a day may increase the risk for breast
cancer in women.183, 184-188 Every additional drink
per day may further increase the risk for breast
cancer as does the number of years a woman has
consumed alcohol. 183, 184, 186
Cardiovascular disease: Some evidence suggests
that the effects of alcohol on the cardiovascular
system are dose-dependent. Low to moderate
doses can be beneficial in some cases.42, 63, 89, 200
These beneficial effects may not be directly due
to alcohol consumption with recent research
raising many questions about this association.200-203
Heavy drinking can lead to increased mortality,
coronary heart disease, peripheral artery disease,
heart failure, stroke, hypertension, and abnormal
amounts of cholesterol or fat in the blood.56, 63,
204-206 The effects on stroke depend on type low
to moderate drinking may only protect against
ischemic stroke (blood clots) and not other types
of stroke, while heavy drinking increases the risk
for all types of stroke. 205, 207
16
CPHO REPORT 2015
Short-term Impacts
Short-term impacts are often a result of being
intoxicated (being drunk) or drinking enough
to impair judgement. In extreme cases, alcohol
poisoning can occur. Outlined below are examples
of short-term impacts of alcohol consumption:
Alcohol poisoning: When levels of alcohol in the
brain are high or toxic enough to have an impact
on areas important for essential functions, alcohol
poisoning can occur.208, 209 Symptoms include:
confusion, stupor, coma, inability to wake up,
vomiting, seizures, slowed breathing, irregular
breathing, hypothermia, and suppressed vital
functions.209 Between 2009 and 2011, an average
of 232 deaths per year from alcohol poisoning
occurred in Canadians 15 years of age and older.210
Homicide: Homicide has been decreasing
substantially over time. In 2013, it constituted
approximately 0.1% of all violent crimes in Canada,
resulting in 505 homicides in 2013.211 Alcohol and
other drug use is common in homicides in Canada,
for both the accused and the victim. In 2013, an
estimated 40% of accused and 32% of victims
involved in a homicide in Canada had used alcohol
at the time of the crime.211
Who is drinking and driving in Canada?1, 8
Most people charged with impaired

driving are men, but the gap has been
closing recently with the rate of women
being charged with impaired driving
increasing since 2005.
Rates of impaired driving are highest in

the Northwest Territories, the Yukon,
and Saskatchewan and lowest in Ontario
and Quebec.
Rates of impaired driving are lowest in

metropolitan areas.
Impaired driving incidents happen most

often during weekends and soon after
bars close.
For licensed drivers, rates of impaired

driving are highest in 20 to 24 year olds
followed by 25 to 34 year olds.
However, the third highest rate of

impaired driving is found in 16 to 19 year
olds despite the fact that fewer people
in this age group drink than any other
age group.
What is intoxication?
According to the World Health Organization, intoxication is a condition that results
from taking a psychoactive drug. It depends
on the dose taken and a persons unique
characteristics, such as level of tolerance.
For alcohol, intoxication is often called
being drunk and can lead to feeling flushed,
slurred speech, lack of coordination, euphoria, being more active and talkative,
disorderly behaviour, slower reactions, and
impaired judgement.
Impaired driving: Impaired driving is the leading

cause of criminal death in Canada.8 In 2012,
523 Canadians died in fatal accidents involving
alcohol, which is a decrease from 1,296 in 1995.212, 213
In 2012, this accounted for a third of all fatalities
in motor vehicle accidents in Canada.213
The Criminal Code of Canadas section 253
describes the offence of operating a vehicle
while impaired and includes a threshold for blood
alcohol levels. As levels of alcohol in a drivers
bloodstream increase, so does the risk for vehicle
accidents.214 Provinces and territories also have
legislation and programs to reduce impaired
driving.5
Since the 1980s, incidents of impaired driving
have decreased substantially. In 1998, there were
over 87,000 incidents of impaired driving linked
to alcohol. The number of incidents has fluctuated
over the years, reaching a low of over 76,000
incidents in 2006 before increasing again to a
high of over 86,000 in 2009. More recently, the
number of incidents has again decreased to over
72,000 in 2014.2, 215
17
Impacts on Mental Health

Alcohol is a risk factor for several mental illnesses
while some mental illnesses precede heavy
drinking.216-219 At the same time, many of the
risk and protective factors are the same for both,
meaning that mental illness and drinking may be
driven by other factors.220
In Canada, rates of death from alcohol-related
suicide are linked to drinking patterns within a
population.221 Data from the early 2000s show
that approximately 25 to 30% of suicides in
Canada were linked to alcohol.221 However, the
link between alcohol and suicide is part of the
broader and complex connection between alcohol
and mental health.
Alcohol and Families: Problems with

drinking tend to run in families due to a
complicated interaction among alcohol
consumption, genetics, and the social/family
environment.246-248 For example:
The earlier people start drinking, the more

likely genetics plays a role in the development of alcohol dependence.246
Children of parents who drank heavily

per occasion tended to have their first
drink earlier, drink more as they get older
and experience more negative life events
in adulthood.19, 36
University students with a family history

of problems with alcohol have a higher
risk for harm from drinking alcohol.249
These intergenerational effects interact
to create a complicated web of impact
on children and future generations.250
Depression: Alcohol and depression are

strongly linked.222, 223 Rates of alcohol
use are higher in people with depression.
Heavy drinking per occasion is linked to
an increased risk for major depression,
especially for women.222, 224226 Some
evidence suggests that alcohol abuse or
dependence could lead to depression.225
Post-traumatic stress disorder (PTSD):
A link exists between alcohol use disorders
and PTSD.227232 Alcohol is sometimes used
to cope with the symptoms of PTSD, despite
the fact that drinking is associated with
the onset of PTSD and the severity of its
symptoms.230, 232, 233
Anxiety: Anxiety is linked to alcohol use.234239
In the short-term, alcohol can reduce
anxiety and panic, but withdrawal from
alcohol can increase anxiety.234 Women
are more likely to drink to cope with social
anxiety than are men.240
Personality disorders: Alcohol is linked to
a variety of personality disorders, including
antisocial personality disorder and narcissistic
personality disorder.241-245
18
Health Benefits from

Drinking Alcohol
Some evidence suggests alcohol may be beneficial for a limited portion of the population, with
the effect being most associated with wine.251256
Research indicates that youth do not benefit from
alcohol at any dose.42 Low to moderate levels of
alcohol consumption have been linked to reduced
mortality from some diseases and lower rates of
diseases such as diabetes, cardiovascular problems, and cognitive impairments. However, this
is a complex story, as some evidence suggests
that the benefits from alcohol consumption are
not relevant for all individuals, at all ages or in
all situations. Benefits could also be due to other
factors in some cases or are based on research
with methodological issues.53, 54, 56, 57, 59, 61, 6365, 69, 73,
7680, 84, 87, 89, 9092, 256261
Moreover, risks and benefits can occur at the

same time. While low and moderate levels of
alcohol consumption maybe beneficial in some
situations, one drink more than the recommended
amounts can increase the risk for several types
of chronic illnesses.42, 184, 186, 187, 262 There are other
less risky behaviours that can be adopted to
achieve the reported health benefits of low
to moderate alcohol consumption, such as a
healthy diet and physical activity.e.g., 263265
CPHO REPORT 2015
Social Benefits: Drinking alcohol may also

have social benefits, such as being part of
some cultural traditions.266 Drinking alcohol
is strongly tied to being social, enjoyment
and positive social experiences.31, 32, 267
Alcohol consumption can be a powerful
social motivator that can help form new
friendships and strengthen existing ones.32,
268, 269 For some people, drinking is associated with positive mood, relaxation and in
some cases, positive mental well-being.
However, these benefits may be culturally
specific and can occur at the same time as
negative outcomes on other measures
of health.267, 270271
In addition, it is possible that the benefits
are not from alcohol per se, but rather the
positive social expectations and experiences
associated with drinking.271
19
PATHWAYS
TO IMPACTS:
FROM BRAIN TO
BEHAVIOUR
Alcohol can have a variety of direct immediate or short-term effects on biology
that can result in impacts on health, well-being, and behaviour. In order to
understand how alcohol creates social impacts, it is important to understand
drinking patterns and alcohols pathway from the brain to behaviour.
Importance of Drinking Patterns

How much and how often an individual drinks are
key factors that increases or decreases the risk
for impacts from alcohol. Abstinence prevents all
direct alcohol-related impacts on an individual.
Some negative health impacts are temporary
and can be reversed or reduced once a person
stops drinking or drinks within recommended
guidelines.e.g., 272, 273
Alcohols impacts are dose-dependent (e.g.,
volume consumed), but also depend on type of
drink and the pattern of consumption over time
(e.g., drinking patterns). To that end, experts have
developed low-risk drinking guidelines to help
Canadians understand how much is too much.42
Categories of diagnostic criteria: 274
Risky use
Lack of control over use
Social and occupational impairment
Needing more drug over time to have an
effect (i.e. tolerance) and/or experiencing
withdrawal symptoms
Alcohol use disorders: Alcohol use disorders

are associated with heavy drinking, but are not
diagnosed by use alone. The Diagnostic and
Statistical Manual of Mental Disorders, 5th edition
(DSM-V) is a diagnostic tool used by health care
professionals to diagnose and determine treatment for mental health disorders.274 Previous
editions defined problems with psychoactive
substances through two distinct categories of
abuse (based on risky use and the resulting social
and occupational impairments) and dependence
(based on resulting health problems, physiological dependence, cravings, lack of control over
use, and time spent seeking, using or recovering
from use).275 In 2012, approximately 5 million Canadians (or 18 % of the population) aged 15 years
and older met the criteria for alcohol abuse or
dependence at some point in their lifetime.276
The DSM-V defines substance use disorders along
a continuum of severity rather than as distinct
conditions. For diagnosis, there are a variety of
criteria that must be met with severity being
gauged by how many criteria a person fits.
Substances use disorders are defined for nine
groups of psychoactive substances: alcohol;
cannabis; hallucinogens; inhalants; opioids;
sedatives, hypnotics and anxiolytics; stimulants;
tobacco; and, other substances.274
20
CPHO REPORT 2015
CANADAS LOW-RISK ALCOHOL DRINKING

GUIDELINES RECOMMEND THAT:
To reduce risks of short-term injury and harm:
Women should have no more than 3 standard
drinks on any single occasion.
Men should have no more than 4 standard
drinks on any single occasion
WHAT IS A STANDARD DRINK?

REGULAR BEER
341 mL = 12 oz
5% alcohol
To reduce long-term health risks:

Women should have no more than
10 standard drinks a week, with no more
than 2 drinks a day on most days.
WINE
142 mL = 5 oz
12% alcohol
Men should have no more than 15 standard

drinks a week, with no more than 3 drinks
a day on most days.
FORTIFIED WINE
85 mL =3 oz
1618% alcohol
Due to the health risks involved, abstinence

is recommended:
During pregnancy or when planning to
become pregnant, and before breastfeeding;
HARD LIQUOR
43 mL = 1.5 oz
40% alcohol
Before and while driving or using machinery

and tools;
When complications with medications
or other drugs are possible;
When living with mental or physical
health problems; and
Before and during any activities that
need judgment, physical skill, balance
and endurance.
Youth should delay drinking alcohol as long as possible, at least until reaching the legal drinking age.
From Brain to Behaviour

Stress and Alcohol
A healthy response to stress
is essential for good health.283
Drinking alcohol can negatively
affect how the body reacts to
stress,284291 which in turn, may
underlie some of alcohols effects
on health and well-being.290
As a psychoactive drug, alcohol acts on the brain,

leading to changes in behaviour.
Alcohols effects are dose-dependent and differ
from individual to individual. Generally, alcohol
initially acts as a stimulant then a depressant.277
Alcohol interacts with two widespread chemicals
in the brain: gamma-aminobutyric acid (GABA)
and glutamate. Alcohol stimulates GABA receptors
(which are inhibitory) and inhibits glutamate
receptors (which are excitatory), leading them to
work together to suppress activity in certain areas
of the brain.45, 100
21
Figure 5:
A SCHEMATIC OF THE WIDESPREAD IMPACTS OF ALCOHOL
ON RISKY BEHAVIOUR
ALCOHOL
INCREASED RISK OF
LONG-TERM IMPACTS
OTHER SHORT-TERM IMPACTS
DRINKING
MORE
ALCOHOL POISONING
HOSPITAL
DECREASED
INHIBITIONS
OTHER
DRUGS
RISKY
BEHAVIOUR
FATALITIES
OVERDOSE
HOSPITAL
FATALITIES
UNPLANNED
PREGNANCY
UNWANTED OR
UNPROTECTED
SEX
ACCIDENTS
IMPAIRED
DRIVING
AGGRESSION
VIOLENCE
CRIME
ABUSE
References: 4, 6, 9, 4244, 86, 93, 125, 146, 208-210, 214, 295, 309, 311, 312, 315-327.
ACCIDENTS
SEXUALLY
TRANSMITTED
INFECTIONS
22
Drinking alcohol acts on the brain to create a

pleasant feeling and has a reinforcing effect on
the brains reward (dopamine) system with the
help of other brain chemicals (e.g., opioids, stress
hormones). Alcohols effect on the reward system
is thought to be the mechanism by which addiction to alcohol develops.45, 95, 124, 262, 278-280
Alcohol easily reaches the brain and can
adversely affect processes that are essential for
healthy brain growth and functioning. At higher
amounts, it can also damage a wide range of
areas in the brain that are important for learning,
memory, decision making, motor control, and
emotion.100, 208, 281, 282
From Behaviour to
Social Impacts
Over the short term, alcohol consumption
can decrease inhibitions and increase risky
behaviour.e.g., 93, 291-293 This can lead to a variety of
potential impacts (see Figure 5) including risky
decisions such as deciding to drive after drinking
or having unprotected sex.93, 295 Drinking patterns
are also linked to unwanted sex and rape among
students.296298 Alcohol can be considered a date
rape drug.296 Drinking alcohol can also be used
to help ease sexual interactions in consensual
situations.299
Alcohol dependence can also increase emotional
reactivity and lead to an inability to interpret
emotions, language and humour.300302 In some
cases, heavy drinking is associated with increased
social rejection and smaller, less diverse social
networks.303, 304 Families can also be affected by
alcohol. For example, how much a person drinks
can influence how much their partner drinks.305
Marital dissatisfaction and divorce can result when
one partner drinks heavily.305307 An increased
risk for partner violence, negative interactions,
aggression, and child abuse and neglect is also
linked to heavy use of alcohol.248, 307313
CPHO REPORT 2015
SUMMARY OF ALCOHOLS IMPACTS

ON BEHAVIOUR
Alcohol-induced disinhibition can facilitate risky behaviour which can lead to
a variety of negative outcomes such as
impaired driving, accidents, rape, sexually
transmitted infections, aggression,
and violence.
Alcohols effect on cognition can affect

a persons ability to learn and work
effectively, leading to poor academic
performance and impaired occupational
functioning. In turn, this can lead to
dropping out of school or unemployment.
Alcohol can have a negative impact on

relationships with family and friends.
Parents, other adults and older siblings
can act as role models for children and
youth, passing on risky drinking patterns
to the next generation.
Impaired motor skills from drinking

alcohol can lead to an inability to drive
safely, leading to a higher risk for accidents that can affect the drinker and
other Canadians.
23
INFLUENCING
FACTORS
A variety of factors play an important role in whether or not alcohol impacts

an individual or population. Some factors are risk factors and some are
protective; however, many are linked to the social determinants of health.
The social determinants of health play a role in health inequities and help
define an individuals or a populations social, economic, and physical
environment, as well as an individuals characteristics and behaviours.328, 329
Social acceptability: When a drug is socially

acceptable, people are more likely to use it and
pressure others to use it too. Alcohol is an example of a drug that is socially acceptable in some
areas of the world despite its risks for harm.
Alcohol is most often consumed for enjoyment,
to be social, and to celebrate despite awareness
of the risks involved.31, 32, 267 In some situations
drinking alcohol is not acceptable, such as when
it leads to violence, before and while driving,
when underage or during pregnancy.42
Stigma and discrimination: Despite being socially
acceptable, the use of alcohol can also lead to
stigma and discrimination, particularly for those
who are being treated for alcohol use disorders.304, 334336 On the other hand, stigma is also
attached to abstinence. Non-drinkers can be
reluctant to disclose their non-drinking status
because of this stigma and in order to be socially
accepted.336, 338
HISTORY
Humans have a long history and, arguably,
fascination with mind-altering drugs,
including alcohol.266, 330, 331 Not long ago,
alcohol was illegal in many jurisdictions
and remains highly regulated in some
areas of the world today.48
Prohibition of alcohol in the early 1900s

in North America arose out of concerns
for its negative impacts. Based on data
from the United States, prohibition of
alcohol initially decreased drinking rates.
These rates returned to pre-Prohibition
levels in the decade following the end
of Prohibition.332
Like other psychoactive drugs, alcohol

was explored for its medical qualities.
More specifically, the idea that moderate
drinking could have health benefits started
in the 19th century.333 Until recently;
however, it was less clear what defined
the difference between low- and highrisk drinking.42
24
CPHO REPORT 2015
CANADA AND THE WORLD48

From 2008 to 2010, average alcohol
consumption per person in Canada was
below the alcohol consumption of many
developed countries.
Canada
Canadians reported drinking 8.2 litres
of pure alcohol per year.
23% of drinkers drink heavily.

United States
Americans reported drinking 8.7 litres
Australia
Australians reported drinking 10.4 litres
13% of drinkers drink heavily.

* Annual consumption was averaged from 2008 to 2010
and measured in pure alcohol per capita in Canadians aged
15 years
and older.
** For these data, heavy drinking was defined as consuming at least 60 grams or more of pure alcohol on at least
one occasion in the previous month.
Note: 10 litres of pure alcohol is equivalent to over 580
drinks of regular beer (at 5% alcohol and 341 mL per drink).
24.5% of drinkers drink heavily.

United Kingdom
People from the UK reported drinking 10.4
litres of pure alcohol per year.
33.4% of drinkers drink heavily.
LOCAL CONTEXT
Drinking patterns differ across the world, shaped
by the local context of where people live, including:
local laws, regulations, and policies related to
alcohol; history, cultural and religious beliefs and
attitudes; and, the social determinants of health.31,
48, 331 In addition, major political, economic and
social events can influence a countrys drinking
pattern.339341
Drinking around the world: Globally, developed
countries show the highest rates of alcohol use
while eastern Mediterranean countries have very
low rates.48 In many developed countries, rates
of risky drinking are increasing in young people,

particularly in young women.342 Other shifts in
drinking rates are occurring in different areas
of the world. For example, India and China are
currently seeing large increases in drinking. These
increases are strongly influencing the overall
picture of global drinking patterns.48
There are also shifts in alcohol consumption being
experienced in the United Kingdom and France,
areas of the world with specific stereotypes
related to alcohol. In the United Kingdom, rates
of binge drinking have been decreasing while in
France, rates of binge drinking have been increasing in youth.343-345
25
Figure 6:
WHAT PERCENTAGE OF CANADIANS A) DRANK ALCOHOL
IN THE PREVIOUS YEAR OR B) UNDERTOOK RISKY DRINKING
IN 2013?
30
84
82
25
ESTIMATED PERCENT
ESTIMATED PERCENT
80
78
76
74
72
20
15
10
70
5
68
0
BC
A
B
SK
M
B
O
N
Q
C
N
B
N
S
PE
I
N
L
C
D
N
66
BC AB SK MB ON QC NB NS PEI NL CDN
Estimated percentage of Canadians 15 years of age and older who had a) consumed alcohol in the year previous
or b) consumed alcohol the week prior to a 2013 survey in amounts that exceeded the guidelines for risks of
immediate impacts or long-term impacts. Data from the territories were not collected.1
Drinking patterns across Canada: Even within

a country, drinking patterns can differ. In 2013,
rates of past year use of alcohol were highest in
Quebec and lowest in Newfoundland and Labrador.
However, rates of risky drinking among drinkers
were highest in Newfoundland and Labrador and
lowest in Quebec1 (see Figure 6). Other surveys
show that people in the Maritimes drink more
alcohol in a sitting while people in the Prairies

drink less, both in terms of amount and frequency.
People from Quebec, Ontario and British Columbia
drink more frequently and drink most often
during a meal.346
26
CPHO REPORT 2015
Statistics Canada also collects data on drinking

that exceeds the guidelines for short-term risks
(i.e., 5 drinks or more for men and 4 drinks or
more for women on one occasion at least once a
month in the previous year). This provides a more
comprehensive picture of risky drinking than
asking about drinking in the previous week.
INDIVIDUAL FACTORS
In 2014, almost 18% of Canadians reported drinking heavily.347 Ontario and British Columbia
consistently had rates below the overall Canadian
rate (both approximately 16% in 2014) while data
from Nunavut suggest similarly lower rates. The
Northwest Territories (32.7%), the Yukon (27.8%)
and Newfoundland and Labrador (25.4%) had the
highest rates (see Table 3).347
Motives for drinking define why people drink

alcohol. Generally, there are four main reasons
why people drink: to be social, to create a positive
mood, to cope, or to conform.348-350 Coping and
conforming are considered negative motives, with
drinking to cope more likely to be associated with
alcohol use disorders.348351 How alcohol is linked
to a persons identity and self-image plays a role
in the impact that motives have on drinking
patterns.349
Table 3: RATES OF HEAVY

DRINKING IN 2014
TOTAL
MEN
WOMEN
British Columbia
15.8
19.9
11.8
Alberta
18.9
23.1
14.6
Saskatchewan
19.5
25.7
13.3
Manitoba
17.8
22.5
13.2
Ontario
16.2
20.7
11.8
Quebec
20.2
25.8
14.8
New Brunswick
21.4
27.8
15.3
Nova Scotia
20.1
24.5
15.9
Prince Edward
Island
16.9
21.0
13.1
Newfoundland
and Labrador
25.4
33.2
18.0
Yukon
27.8
32.6
22.7
Northwest
Territories
32.7
39.1
26.3
Nunavut
14.3*
17.4*
11.0*
Canada
17.9
22.7
13.2
Estimated percentage of Canadians 12 years of age

and older in 2014 who had reported drinking heavily
on one occasion at least once a month in the previous
year. Heavy drinking was defined as drinking 5 drinks
or more for men and 4 drinks or more for women.347
* Data should be used with caution.347
Drinking patterns not only differ significantly

across populations, they also vary widely between
individuals. There are several factors that influence how much people drink and their risk for
impacts from drinking alcohol.
Heavy drinking among young adults is often

the result of intending to drink heavily. Many
factors influence this decision-making process,
including social norms and future plans.352 Factors
that occur during a drinking episode can also
change how much is consumed, including
available funds, behaviour of friends, mood
and transportation options.352
Cues that are unique to an individual and related
to alcohol, such as certain friends or specific
locations, can increase the need for alcohol
as well as the potential for negative consequences.355, 356 How a person feels while drinking
can affect their subsequent alcohol use. When
heavy drinkers drink alcohol, they experience a
more intense stimulating effect and a less intense
depressive effect than do light drinkers. This
effect was linked to an increased risk of binge
drinking among heavy drinkers at a later date
and of developing an alcohol use disorder.357359
Different locations can strongly influence drinking
patterns. Generally speaking, certain locations
are associated with drinking and tend to increase
the potential for heavy drinking.360364 Drinking
at locations such as pubs and off-campus housing
can lead to more drinking among university
students.365, 366 Drinking at a friends house or in a
restaurant is associated with lower levels of drinking
among adults.364, 367 Becoming a parent is related
to decreased drinking, which is likely at least
partially due to less time spent at locations where
heavy drinking is more prevalent (e.g., bars).364
27
Friends strongly influence drinking habits.

Drinking alcohol is strongly linked to being social.
In fact, young people will emphasize positive
social experiences associated with drinking to
compensate for the negative impacts.267 Drinking
patterns within a social network have an important impact on use.26 Having more friends who
drink is linked to heavy drinking, although
loneliness is also linked to heavy use.365, 366 Social
support can sometimes decrease how much
alcohol is consumed.365, 367370
Context is also important drinking alcohol with
meals tends not to lead to the same negative
impacts as drinking alcohol at other times.428, 429
When many people are intoxicated together or
drinking games are involved, more alcohol tends
to be consumed.360
HOW DO EXPECTATIONS
INFLUENCE ALCOHOLS EFFECTS?
The effects of alcohol are mediated by the
expectations of the drinker. People are poor
at judging how intoxicated they are, leading
to the belief that they are more capable of
doing certain activities such as driving
safely, than they actually are.353,354
Various events that happen over a persons

lifespan affect drinking patterns and the risk
for impacts from alcohol.93, 305307, 348427 For
example:
Poor academic performance
Some personality traits have been linked to

increased risk for impacts from alcohol. Impulsivity
and sensation seeking are associated with
increased alcohol consumption. In turn, these
traits are linked to increased alcohol-related
negative health impacts, including alcohol use
disorders.98, 104, 107, 116, 430435
Problems at school
For some people, stress can trigger a need for

alcohol as a method of coping, which can create
a cycle of stress and alcohol use.348, 367, 404, 406411,
Divorce
414, 415, 417, 419, 423, 427, 436
Dropping out
Moving from high school to university/
college
Unemployment
Stress at work
Marital conflict/dissatisfaction
Partner who drinks heavily
Stressful life events
MODIFYING RISK FACTORS

In addition to personal triggers, there are other
risk factors that can result in some people being
more at risk for negative impacts than others.
These include:
Genetics and Epigenetics: Genetics play a
strong role in becoming dependent on alcohol,437442 with some evidence suggesting that
genetics contribute approximately 50%.438, 440
Genetics affect the risk for impacts from
alcohol through a variety of mechanisms. For
example, genes can affect how people metabolize alcohol or the development of personality
traits that are linked to alcohol use.443445
Epigenetics looks at how different factors can
turn genes on or off and how these changes
in gene activation can be passed on to future
generations.446 This is still a growing area of
research, including for alcohol.447449 The
epigenetic effects of alcohol can be seen
Marriage
Becoming a parent
Retirement
Aging
through the impacts of drinking before conception. For example, heavy drinking during the
preconception period by a mother or father
can affect the development of their child.450, 451
Epigenetics also plays a role in a variety of risk
factors that influence the use of alcohol such
as stress and early development.452457
Biology: Alcohol is most often consumed as a
beverage and enters the bloodstream via the
digestive tract. Blood levels of alcohol depend
on a persons metabolism and increase when
more alcohol is consumed, when people have a
higher body fat content, when less food is
present in the digestive system and with the
use of some medications.45, 100
28
CPHO REPORT 2015
Sex: Women and men tend to differ in body

fat percentage and in how they metabolize
alcohol. Reduced amounts of certain
enzymes and other sex differences in
metabolism lead to more alcohol entering
the bloodstream in women than men when
the same amount is consumed.45, 100
Aging: With age, risks from alcohol may
increase as people become more sensitive
and less tolerant to alcohol.386, 458-464 As a
result, alcohol has a greater impact on
people who are older than 65. People tend
to drink less alcohol as they age, although
this may be changing.465
Stress, depression and life events and
transitions linked to aging such as death of
a spouse or divorce, loss of social networks,
a change in health status or retirement can
impact drinking patterns.466
Underlying health conditions: Alcohol can

exacerbate poor health. Generally, alcohol
impairs the immune system, although it does so
in a dose-dependent manner.96, 109, 115, 127 Alcohols
impacts on the immune system could make
existing health conditions worse.96, 109, 115, 127
Alcohol also contributes to the development
and progression of non-alcoholic fatty liver
disease, which is largely caused by obesity.467
It can also hasten the progression of HIV and
hepatitis C.468-473 Alcohol can modify the
effectiveness of various medications, including
drugs for conditions such as arthritis, diabetes,
heart disease, enlarged prostate, high cholesterol, heartburn, indigestion, high blood pressure,
infections, depression, anxiety, epilepsy, seizures,
attention deficit/hyperactivity disorder, blood
clots, nausea, insomnia, and allergies. Other
examples include pain killers, cough syrups,
anti-cancer drugs and anti-retrovirals.474476
Socioeconomic status (SES): SES is a factor

that is based largely on income, education and
employment.477 As a risk factor for problems
with alcohol, the link between SES and alcohol
is complex and influenced by other factors,
such as drinking pattern, age, gender, parental/
childhood SES, neighbourhood characteristics
and country of residence.478493 In Canada, men
and women with high SES are more likely to
drink and undertake risky drinking than those
with low SES.342 In general, people with low
SES are more likely to experience negative
impacts from drinking.490, 492, 493
Occupation: Beyond its role in SES, employment can modify alcohols impacts on health. In
Canada, different types of jobs were not linked
to risky drinking.494 Characteristics of work or
the labour market rather than the job per se
were more likely to affect drinking patterns.
For example, social support, job motivation,
and job satisfaction were related to low alcohol
consumption. Stress, overwork, long hours,
harassment, and job insecurity were linked to
risky drinking. Control over decisions was
linked to both high and low alcohol consumption.495506 Factors outside the workplace seem
to have a greater impact on drinking patterns
than work-related factors.494
Certain types of jobs or activities involve a
sub-culture of drinking alcohol. For example,
alcohol is an integral part of life for musicians,
as is job insecurity, stress and the need to
socialize for work all of which are linked to risky
drinking.507, 508 Alcohol is also a part of sports
culture. Student athletes are more likely to
drink than student non-athletes, although this
depends on time of year (e.g., on- versus
off-season), sex, level of competition and type
of sport in some situations.509519 In addition,
students who were fans of sports at college
were also more likely to drink and drink heavily.520 There is some evidence that teenagers
involvement in sports may lead to heavier
drinking later on.521, 522
29
Alcohol and Other Drugs: Drugs are often

discussed in isolation, but in reality, some are
frequently used together (known as polydrug
use). The risks for harm increase with polydrug
use.97, 318, 324, 326, 523 For example:
Alcohol and caffeine is a combination that
is a public health concern, particularly with
respect to youth and the use of energy
drinks.524, 525 Caffeine and alcohol together
may increase the risks for harm from alcohol.
People who combine alcohol and caffeine
often increase their consumption of alcohol
and report feeling less tired and more alert,
as well as feeling less intoxicated than they
actually are.525532 Mixing alcohol and caffeine
is also often associated with increased
risky behaviour.533, 534
When combined, alcohol and marijuana can
increase motor control problems, leading to
higher risks for motor vehicle accidents than
the use of either drug alone.535 This is likely
due to the fact that alcohol increases marijuana metabolites in the bloodstream,
increasing the impacts of marijuana on
behaviour.536, 537
Separately, alcohol and tobacco can strongly
impact long-term health. Together, they can
further increase this impact. For example,
the risk for oral and pharyngeal cancers in
people who both drink heavily and smoke
tobacco is 300 times higher than for people
who neither drink nor smoke.538
PROTECTIVE FACTORS
Certain factors can protect against the negative
impacts of alcohol, notably reducing consumption.
Many protective factors are the same for adolescents as they are for young adults.539 Attending
religious services or activities, being more
attached to parents, having high levels of family
support, strong family management (e.g., rules,
monitoring, consistent discipline, reinforcing good
behaviour), having good social skills and sense
of morality. social conformity, and being prosocial
(e.g., working hard at school, helping at home,
being involved in community activities, etc.) are
all factors that are linked to reduced drinking
among youth and young adults.539, 540
Protective and risk factors are not the same
everywhere, with differences contributing to
drinking rates and patterns.541 Some traits, such as
self-esteem, can also have an impact on alcohol
consumption, although the effect is complex and
can depend on drinking motives or context.542, 543
Certain strategies can also help protect against
the negative impacts from alcohol, including
setting limits, adjusting limits to recognize risk
factors (e.g., age, body weight), drinking slowly,
alternating between alcoholic and non-alcoholic
drinks and eating before and while drinking.544
POPULATION
HEALTH
PERSPECTIVE
Based on existing information, alcohol consumption is discussed in three
specific populations below youth, women and Aboriginal populations:
YOUTH
Alcohol is a public health concern for youth because:
Drinking patterns established during adolescence are important predictors of drinking
patterns and their impacts in adulthood. The
younger a person starts drinking, the higher
their risk for poor health and problems with
alcohol later in life.545555
Girls may experience more impacts from
alcohol on the brain than boys.556 While drinking rates for girls are lower than for boys, rates
of becoming intoxicated are similar.555
Teenage brains, particularly those of teenage
girls, are more vulnerable to the effects of
alcohol, resulting in various impacts on developing cognition and behaviour.281, 555567 How
the brain influences drinking behaviour may
differ between teenaged boys and girls.556, 568
Youth who drink heavily can have trouble with
attention, memory and decision-making and
can experience social, emotional, and behaviour
problems.559, 565 Problems with alcohol can lead
to poor academic performance, dropping out,
poorer job possibilities, and social isolation.93,
105, 299, 342, 569572
Youth are strongly influenced by friends and

family. For example, when youth believe that
their friends are drinking heavily, they drink
heavily too. Also, when friends and parents
approve of drinking alcohol, youth are more
likely to drink and suffer negative impacts
from drinking.571
WHY DO YOUTH TRY ALCOHOL? 431,

467, 560-564, 568, 573-576
Youth tend to be more impulsive, seek

out new experiences and take more risks.
Youth also tend to have trouble with

self-control and deal with stress differently than adults.
Areas in the brain related to decisionmaking, motivation, emotion, and reward

are still developing. In fact, brain development continues into young adulthood.
31
Data on Youth and Alcohol Consumption in

Canada: The age at which youth take their first
drink in Canada has been increasing.599 An estimated 60% of Canadians aged 15 to 19 years drank
alcohol in 2013. An estimated 15% of these youth
drank enough to exceed the adult low-risk drinking
guidelines for acute effects, while almost 20%
exceeded the adult guidelines for chronic impacts.1
Many Canadians begin drinking before the age
of 15. The phenomenon of students binge drinking
or getting drunk is infrequent in lower grades
and becomes much more common in higher

grades (see Figure 7).555, 599 By grades 10 to 12,
almost 60% of teenagers reported having had a
drink in the previous year while about 46% reported
having undertaken binge drinking in 20122013.
This is a decrease from previous years. For example,
over 70% of students in Grades 10 to 12 reported
drinking in the past year with almost 60% binge
drinking in 2008-2009.599601 In 20122013, about
50% of youth reported having had their first drink
of alcohol between the ages of 12 and 14.602
Figure 7:
WHAT PERCENTAGE OF STUDENTS A) DRANK ALCOHOL
OR B) UNDERTOOK BINGE DRINKING IN 20122013?
80
50
70
40
ESTIMATED PERCENT
ESTIMATED PERCENT
60
50
40
30
30
20
20
10
10
0
Grade
7
Grade
8
Grade
9
Grade
10
Grade
11
Grade
12
Grade
79
Grade
1012
Estimated percentage of Canadians in Grades 7 to 12 who a) consumed alcohol or b) undertook binge drinking
(5 or more drink on one occasion) in the year prior to the Youth Smoking Survey 20122013.599
32
CPHO REPORT 2015
Rates of drinking at least once a week by students

in Grades 6, 8, and 10 have decreased, particularly
for beer. However, rates of becoming intoxicated
have been relatively stable since 1994.555
KEY FACTS ABOUT STUDENTS

AND ALCOHOL: 11, 555, 599, 603611
Rates of drinking increase considerably
In every grade, boys consistently drink more

beer than do girls, while consumption of wine,
liquor and coolers is more similar across sexes.
Consumption of beer increases across grades,
while the consumption of wine and liquor is
more stable.555
About 60% of students in Grades 6 to 10 think
drinking once in a while carries little to no risk.
Regular drinking is thought to be risky by around
80% of boys and 87% of girls in Grades 6 to 10.602
Binge drinking (i.e., drinking 5 or more drinks in
a single occasion for boys and 4 or more drinks
for girls) in the previous year was linked to
more emotional and behaviour problems,
particularly in those who undertook binge
drinking most often.602
from lower grades to higher grades and

even more so after the transition to
university and college.
Many university and college students

experience negative outcomes from their
drinking, such as hangovers, fights, and
poor academic performance.
Some students rate negative impacts

such as hangovers and blackouts as
neutral or positive, which is more likely to
lead them to drink more and experience
negative health impacts.
For some students, alcohol can have

positive effects, such as making events or
celebrations more fun. Positive impacts
have a stronger effect on subsequent
drinking than negative impacts.
Drinking games are popular in high school
WHERE DOES PARENTING FIT IN?

Parents can have a negative influence
on their childrens future use of alcohol,
health and well-being through abuse,
neglect, and stress.94, 99, 101, 305, 575-582
Parental drinking predicts alcohol use

in youth.583-585 Parental motives, rules, and
attitudes also affect childrens drinking.585-590
Positive family relationships and parenting practices are linked to reduced

drinking by teenagers, while negative
family relationships, including divorce and
family violence, are associated with more
or earlier drinking.591-598
and university/college and can lead to

many negative impacts.
Holidays and special events such as

celebrating being legal age to drink,
spring break, and athletic events, can
increase drinking, even in students who
tend to normally drink lower amounts.
33
WOMEN
ability to release healthy eggs (which is

essential for conception) in pre-menopausal
women.108, 612
Alcohol is a public health concern for

women because:
As a population, women are less at risk for
negative impacts from alcohol because
they tend to drink less than men. As individuals,
women are more at risk for harm from alcohol
due to biological and social factors.1, 2, 45, 100, 342
Because more women are undertaking risky
drinking over time, this increases the risk that
with time, women will be more impacted by
alcohol as a population.1,2,342
Women can be more vulnerable to sexual
assault or other violence when drinking
beyond their capacity.298, 299
Alcohol consumption can affect fertility. While
moderate levels of drinking are linked to more
sexual activity, they may also reduce the ovarys
Although the impacts of drinking during

pregnancy are well known, over 10% of women
in 20062007 who gave birth reported they
drank while pregnant.613 Drinking before
conceiving can also have detrimental effects on
the development of offspring.450, 451 It is
estimated that 50% of pregnancies are
unplanned, meaning women may consume
alcohol before knowing they are pregnant.171
Alcohols effects on women may be moderated
by the impact of alcohol on hormones. For
example, estrogen levels in women increase
with every drink of alcohol, although the link
between alcohol and estrogen is complex.112, 117,
614 These changes in estrogen may be linked to
alcohol-related effects on breast cancer and
fertility.102, 111, 615617
100
50
90
45
80
70
60
50
40
30
25
20
20
10
10
5
0
Women
Women
35
15
Men
Men
40
30
ESTIMATED PERCENT
ESTIMATED PERCENT
Figure 8:
WHAT PERCENTAGE OF CANADIANS A) DRANK ALCOHOL
OR B) UNDERTOOK RISKY DRINKING IN 2013?
Estimated percentage of Canadians 15 years of age and older who consumed alcohol a) in the previous year
or b) in the week prior to a 2013 survey in amounts that exceed the low-risk drinking guidelines.1
34
Data on Sex Differences in Alcohol Consumption

in Canada: In Canada, a higher percentage of men
than women drink alcohol both in general and in
terms of risky drinking (see Figure 8).1 However, risky
drinking by women in Canada has increased,1, 131, 132,
342, particularly in women above the age of 35.1, 132
Men tend to begin drinking and undertaking risky
drinking at an earlier age than do women,1, 618,
although women progress more quickly from
abuse to physical dependence and to treatment
for problem use than men.619 Men also tend to
drink more for the positive effects and social
aspects of alcohol than women do.620
ABORIGINAL POPULATIONS
Alcohol is a public health concern for some
Aboriginal populations in Canada because:
Many Aboriginal populations face major
challenges that affect their health and wellbeing such as high unemployment, poverty,
poor access to education, poor housing, being
located far from health services, the displacement of Aboriginal language and culture, and
social and economic marginalization.621629
CPHO REPORT 2015
communities are less likely to drink, with approximately 60% saying they did not drink in the past
year. For those youth who did drink, approximately 50% drank heavily.631 In addition, use and
abuse of alcohol and drugs was ranked by First
Nations on-reserve as the top challenge for
community wellness.631
According to the 2012 Aboriginal Peoples Survey,
33% of Inuit 15 years of age and older did not drink
in the previous year, although 26% drank heavily.632
According to the 2007-2010 Canadian Community
Health Survey, 27% of Mtis aged 12 years and
older drank heavily in the previous year.633
KEY DETERMINANTS OF HEALTH

FOR ABORIGINAL POPULATIONS:
621623, 625, 627, 630
Community readiness
Economic development
Employment
Environmental stewardship
Gender
Historical conditions and colonialism
In order to address health issues, there is a

need to understand how Aboriginal social
determinants of health affect and contribute to
a holistic view of health. For Aboriginal populations, historically and culturally specific factors
play a particularly important role.621, 622, 625
Housing
Data on Aboriginal Populations and Alcohol

Consumption in Canada: Findings from the
First Nations Regional Health Survey (2008-10)
indicate that the rate of reported alcohol consumption for First Nations living on reserve is
lower compared to the general Canadian population. However, the rate of reported heavy drinking
is higher than the Canadian rate. Approximately
35% of First Nations adults living in First Nations
communities did not drink in the past year, but
of those who did drink, more than 60% drank
heavily. First Nations youth living in First Nations
Lifelong learning
Land and resources

Language, heritage and strong
cultural identity
Legal and political equity

Living on- and off-reserve
Racism and discrimination
Self-determination and non-dominance
Social services and supports
Living in urban and rural areas
35
REDUCING
HEALTH
IMPACTS
Drinking alcohol is ingrained in Canadian culture. Because there are multiple levels
and types of influence on drinking patterns (see Figure 9), many actors play a role
in promoting responsible drinking and healthy behaviours. Many primary prevention
strategies aim to reduce risky drinking and potential negative impacts of alcohol
consumption; however, none of these are universally effective. The amount of variability across individuals, communities and societies means that there is no single
way to reduce impacts of alcohol use on individuals and populations.5, 342
ADDRESSING INDIVIDUAL
FACTORS
Not all factors that influence drinking can be
addressed at the individual level. Individuals can
reduce their drinking by recognizing factors that
influence them to drink and that increase their risk
for harm.
Reducing consumption: The amount of alcohol
consumed plays a large role in the risk for both
short- and long-term impacts.42 Once an individual
determines how much he or she drinks, Canadas
Low-Risk Alcohol Drinking Guidelines can help
determine whether or not the amount consumed
is putting the individual and his or her family and
friends at risk for harm. Some countries, including
the United Kingdom, are currently revising their
low-risk guidelines.634
Brief interventions for alcohol: Following a
screening process, brief interventions aim to
target at-risk individuals through personalized
feedback and counselling to set goals, find
effective strategies to change behaviour, and
provide information and guidance. Interventions
can range from one short session to multiple

sessions depending on the individuals needs.
Individuals can be identified for and referred to
treatment through this process.635
The World Health Organization has a variety
of resources available on brief interventions.
The Canadian Centre on Substance Abuse and
the College of Family Physicians of Canada
have developed a screening, brief intervention
and referral guide.
Brief interventions have been noted as an
important component for reducing the impacts
of alcohol on individuals and act as a bridge
between prevention and treatment.635637
A number of randomized trials in several countries
have demonstrated that brief interventions are
effective in many settings.636 Brief interventions
can reduce drinking, decrease mortality rates
and improve health.638640
Although brief interventions are

effective, social norms interventions
(i.e., providing information on how
much other people are drinking)
are largely ineffective.641, 642
36
CPHO REPORT 2015
Recognizing and addressing risk: Addressing risk

factors that influence drinking is an important step
in reducing the potential for impacts. For example,
why people drink is an important factor in determining what approach would work best for an
individual.643 For those who use alcohol to cope
with stress, healthy coping skills and lifestyles

can help reduce drinking and related impacts.644646
Using protective behaviours such as eating
before drinking, alternating non-alcoholic with
alcohol drinks and pacing drinks, can decrease
the negative impacts from alcohol.647
Figure 9:
TYPES AND LEVELS OF INFLUENCE
ON ALCOHOL CONSUMPTION
INDIVIDUAL
Reaction to alcohol:
Life transitions:
Stimulating
Metabolism
Genetics
Expectations
Personality:
Impulsive
Sensation seeking
Going to school
Finding or losing a job
Getting married
Getting divorced
Becoming a parent
Retiring
Stress:
Coping
Makes alcohol more rewarding
FAMILY AND FRIENDS

Friends
Family:
Drinking patterns
Peer pressure
Behaviour
Social support
Role models
Parenting
Abuse, stress, family violence
Beliefs and attitudes toward alcohol
Letting children try alcohol
COMMUNITY AND SOCIETY

Availability:
Social acceptability:
Cost
Ease of access
Retail outlets
Social expectations
Acceptable in certain situations
(e.g., parties, celebrations, university/colleges)
Not acceptable in other situations
(e.g., pregnancy, before/while driving, when
underage, when violence occurs)
Stigma for those who do not drink
Exposure:
Widely promoted
On tv, on the radio, in
movies, in literature
On social media,
websites
37
Attitudes and beliefs are also important

considerations. For example, skills that help
youth learn how to say no to alcohol seem
only to help youth who already disapprove of
drinking.648 Evidence also suggests that changing
parental attitudes on underage drinking by
making them stricter can reduce heavy drinking
in adolescents.649651 Changing parental behaviour
seems to be a necessary component for reducing
youth drinking over the long term, particularly
for high risk youth.652655
Other risk factors are more difficult to address.
For example, interventions that target personality
traits have mixed effects with some showing
promise and some being largely ineffective.656658
Health professionals can also influence people to
recognize their risk for harm from alcohol. For
example, educating women of child-bearing age
about potential risks from alcohol to their health and
the health of their developing baby is important.659
ADDRESSING AVAILABILITY
AND EXPOSURE
Laws, regulations and policies aim to keep
Canadians safe and help mitigate harm from
alcohol by contributing to changing behaviour.
They also contribute to variability in drinking
patterns across different jurisdictions, including
across provinces.5 Many of these are related to
controlling availability. For example:
Pricing and taxation are tools that can
discourage people from buying alcohol. As
a consequence, this can reduce alcohol-related
health and social impacts, including for impaired
driving and alcohol-related crime.660663 Increasing the minimum price of alcohol is one of the
more effective approaches that successfully
decreases consumption, alcohol-related death
and hospital admissions.660, 662665 Most provinces have introduced minimum pricing;
however, policies on indexation and pricing
on alcohol content are not well implemented
across every Canadian province (data on
territories were not analyzed).5
Control of sales and availability also reduces

the impacts of alcohol use by restricting
eligibility to purchase and sell alcohol as well
as restricting the number of alcohol outlets and
days/hours of sale.666 When alcohol sales are
not controlled, there tends to be higher availability, more drinking, more alcohol related
problems and increased acceptability of alcohol
use.5, 128, 666673 Currently, alcohol is widely
available across Canada.5 The number of
locations that are allowed to sell alcohol in an
area is largely decided at the municipal level;
however, provinces implement various other
means of controlling sales and availability.5
Changing behaviour: Reducing risky drinking

involves a change in behaviour. To change
behaviour, it is important to understand:
what is risky drinking; and

how to reduce alcohol consumption.
The Canadian Centre on Substance Abuse
Canadian Centre on Substance Abuse and
Educalcool have a variety of tools to help
use Canadas Low-Risk Alcohol Drinking
Guidelines as well as tips and resources to
drink responsibly.
Strategies and tools have been developed
to help people reduce their drinking.
For example:
College of Family Physicians Canada and

the Canadian Centre on Substance Abuse:
Drinking Smart
The World Health Organization: Self-help

strategies for cutting down or stopping
substance use
Centre for Addiction and Mental Health:

Saying When: How to quit drinking or
cut down
Programs that aim at improving safety at

drinking establishments (e.g., Safer Bars
Program) show promise in reducing
violence and physical aggression.674, 675
Responsible beverage server training is
also effective in reducing risky drinking.676, 677
Examples include SmartServe in Ontario and
Serving it Right in British Columbia.
38
CPHO REPORT 2015
Minimum age laws also restrict availability of

alcohol by legally defining at what age people
can buy and drink alcohol. When enforced, it is
the most effective means of reducing drinking
among underage youth.678 Consequently, the
impacts of alcohol on measures like mortality,
overdoses, injuries, vehicle accidents and use of
the health care system are also reduced.679684
In Canada, rates of fatalities, including from
motor vehicle accidents, increase at the minimum legal drinking age, more so for men than
women.681 The legal drinking age is 19 years
of age in Canada, except in Quebec, Manitoba,
and Alberta where it is 18.685
Alcohol advertising: In Canada, advertising of
alcohol is regulated by a variety of federal and
provincial statutes and regulations, including
the Food and Drugs Act, Television Broadcasting Regulations and Radio Regulations.
Commercial messages are also to observe the
Code for Broadcast Advertising of Alcoholic
Beverages.
There is very limited research on the effects of
alcohol advertising on Canadians. Based on
research from the United States, evidence has
found that alcohol marketing reaches a wide
audience, including underage youth.686688
Some elements of alcohol ads are particularly
appealing to a youth audience and exposure to
particular brands do increase the likelihood that
youth will drink that brand.687, 689691 However,
research is mixed on if or how alcohol advertising affects drinking patterns. Some results
suggest that advertising increases drinking in
youth who are already more receptive to this
type of advertising or more likely to undertake
risky behaviour.692-694 Other research suggests
that there is a dose response to advertising
the greater the exposure to alcohol advertising, the more youth drink.695 Promoting alcohol
also occurs through other means. For example,
in the United States, the alcohol industry
sponsors a large number of events linked to
sports and music. Brands that are popular with
youth are more likely to sponsor such events.696
Stigma: Addressing stigma for

both people who do not drink
and those who are in treatment
is important. For information on
addressing stigma, see the Mental
Health Commission of Canada.
Safe Alcohol, Safe Drinking: Liquor control

boards and commissions and the alcohol
industry, including producers, restaurants,
bars and night clubs, plays an important role
in reducing risks associated with drinking
alcohol. The safety of alcohol is regulated by
various pieces of legislation, including
through the Food and Drug Act.697
In addition, the alcohol industry in Canada
works in collaboration with government,
non-governmental organizations and other
groups to promote responsible drinking.
For example:
Provincial and territorial liquor control

boards and commissions support a
wide variety of initiatives such as public
awareness and education campaigns.
For more information on the activities of
Canadas liquor boards and commissions,
see the Canadian Association of Liquor
Jurisdictions.
Several industry representatives are

members of the National Alcohol
Strategy Advisory Committee.
Beer Canada, the Canadian Vintners

Association and Spirits Canada provided
support for the development of the
Canadian Centre on Substance Abuse
and the College of Family Physicians
of Canadas screening, brief intervention
and referral tools.
Beer Canada is a partner in a variety of

responsible use programs and supports
a variety of research and knowledge
exchange activities.
The Canadian Vintners Association

actively promotes Canadas Low Risk
Alcohol Drinking Guidelines.
Labatt Brewing Company and AnheuserBusch InBev collaborated to develop

Family Talk as a resource for families
to help prevent underage drinking.
39
ADDRESSING SOCIAL
ACCEPTABILITY
Perhaps the most challenging aspect to tackle in
terms of reducing the negative impacts of alcohol
consumption is social acceptability. Addressing
social acceptability must involve action at the
individual, family, community, and societal levels.
Strategies on Alcohol: Alcohol is a recognized
public health issue both globally and within Canada.
The World Health Organization has developed
the Global Strategy to Reduce the Harmful Use
of Alcohol that outlines ten areas for national
action: leadership, awareness and commitment;
health services response; community action;
drink-driving policies and countermeasures;
availability of alcohol; marketing of alcoholic
beverages; pricing policies; reducing the
negative consequences of drinking and alcohol
intoxication; reducing the public health impact
of illicit alcohol and informally produced
alcohol; and, monitoring and surveillance.
Developed in 2007 in collaboration with a
variety of alcohol stakeholders, Reducing
Alcohol-Related Harm in Canada: Toward a
Culture of Moderation identified a range
of recommendations to form the basis of
a National Alcohol Strategy.
Awareness campaigns: Developing messages
about alcohol that resonate is challenging, making
it difficult to create effective awareness campaigns.342 Interestingly, alcohol is one of the few
health-related topics where mass media campaigns
are rarely effective.698 Awareness campaigns have
had the most success for impaired driving,698701,
suggesting that specific and tangible topics where
messages and actions are clear may benefit most
from awareness campaigns.
Awareness campaigns are important for increasing knowledge and changing attitudes, but they
do not always change drinking behaviour or the
intention to drink.342, 699 There is a lack of awareness among Canadians about the full impact of
alcohol on health. For example, in 2008, almost
70% of Canadians were not aware that alcohol
was linked to cancer, while almost half were not
aware of its links to heart disease and diabetes.702
Increasing knowledge and shifting attitudes is a
key first step in the difficult process of changing
societal views on drinking alcohol. This means
awareness campaigns are an important component of a multi-faceted approach for reducing
the negative impacts of alcohol consumption.
Canadas National Alcohol Strategy:

Formed in 2008, the National Alcohol
Strategy Advisory Committee (NASAC)
leads the implementation, monitoring and
evaluation of the National Alcohol Strategy.
The committee is co-chaired by the Canadian Centre on Substance Abuse, Mothers
Against Drunk Driving Canada, and the Nova
Scotia Department of Health and Wellness
and consists of experts from across Canada
including federal and provincial government
representatives, non-governmental organizations, public health including medical
officers of health, First Nations, Inuit and Mtis
service providers, and the alcohol industry.
Progress has been made on a number of the
recommendations, including: the development of Canadas Low-Risk Alcohol Drinking
Guidelines launched in 2011; staff and server
training programs; policies and programs
for deterring underage drinking; and,
community alcohol awareness campaigns.
In addition to the progress made on the
Strategy, the Public Health Agency of
Canada and Health Canada have also
made progress on addressing fetal
alcohol spectrum disorder.
Public health awareness campaigns

that either use scare tactics or
promote responsible drinking can
increase drinking while knowledge
of drinking guidelines does not
always reduce risky drinking.703705
CLOSING
COMMENTS
My role as Canadas Chief Public Health Officer is to engage Canadians and

this report is meant to support a public health dialogue about drinking and
its risks. The evidence gathered in this report provides an overview of public
health impacts within our Canadian culture that normalises drinking. Information
is organised in a way that recognises that people may choose to read only
certain sections as it is web-based.
As noted by the Canadian Public Health Association in their 2011 position
paper on alcohol, tackling the problematic use of alcohol requires a combination
of factors, including leadership and a broad base of support at all levels.
Since our National Alcohol Strategy was developed in 2007, there is emerging
evidence on increased risks of cancers at low levels of drinking and a growing
skepticism on alcohols benefits. Our knowledge and understanding of alcohol
consumption, drinking patterns, and the health impacts of alcohol in Canada
is inadequate.
I suggest Canadians and our institutions take a closer look at our current
approach and reflect if we are doing enough to reduce the harms associated
with drinking alcohol.
41
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Data and information for this report were collected using a variety of methods,
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report being from peer-reviewed scientific articles and trusted data sources,
such as Statistics Canada. Terminology on drinking, such as heavy drinking,
alcohol abuse, alcohol dependence, and alcohol use disorders, were used as
appropriate and matched the terminology being used in the research and data
being cited. Care was taken not use terms such as alcohol abuse, alcohol
dependence, and alcohol use disorders unless relevant as these conditions are
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